Psychosis and schizophrenia

DeVylder et al’s (2013) American study reports an association between acculturative stress and Psychotic-like Experiences (PLE) among a national community sample of first-generation Asian immigrants. Asian respondents who reported increasing numbers of acculturative stress items were at progressively greater risk for PLE (particularly visual and auditory hallucinations, but not delusions) in a dose–response fashion. Several studies have prospectively demonstrated the associations between daily stress and increased psychotic-like symptom severity among help-seeking youth at clinical risk for psychosis (DeVylder et al., 2013; Tessner et al., 2011). Acculturative stress may likewise consist primarily of the experience of persistent minor hassles (DeVylder et al., 2013). Increased sensitivity to ongoing stressors associated with adjustment and integration to a new culture, and the inability to effectively cope with these ongoing stressors, may contribute to the association between psychosis and immigration. Younger age at the time of immigration has been associated with increased risk of psychosis among non-western immigrants to the Netherlands (Veling et al., 2011). Risk for PLE for ethnic minority immigrants may be related to environmental factors, particularly those that occur or begin during childhood (eg perceived discrimination, childhood separation from parents), with risk increasing as duration of exposure increases (DeVylder et al., 2013).

Dutch studies have found that the incident rate for all psychotic disorders is highest among the ethnic groups who report the most severe discrimination (Eilbracht et al., 2015; Veling et al., 2007). Studies covering different psychotic disorders at different stages of development in different immigrant groups also indicate that high rates of discrimination may be associated with the onset- and/or symptomatic features of the psychotic disorders (Berg et al., 2011; Janssen et al., 2003). A number of studies suggest that immigrants and ethnic minority groups with psychosis have a distinct psychopathological profile compared to patients of the majority culture. There are reports of more hallucinations, primarily auditory, among psychotic patients from a number of ethnic minority and immigrant groups both in the USA and Europe (Berg et al., 2011; Vanheusden et al., 2008).

Perceived discrimination is also associated with the positive symptoms of delusional and paranoid ideation (Janssen et al., 2003). In addition, there are reports of more severe depressive symptoms among both ethnic minority and immigrant patients with psychotic disorders (Veling et al., 2007). These studies have demonstrated that patients from ethnic minority groups appear to exhibit more severe positive and affective symptoms across a broad range of psychotic disorders.

Berg et al. (2011) suggest that discrimination can be an important environmental stressor leading to the development and escalation of both depression/anxiety and positive psychotic symptoms in patients with psychotic disorders. This finding may help to explain the distinct psychopathology profiles reported in different ethnic minorities. The experience of social deprivation based on visible minority status may lead to feelings of hopelessness and an external locus of control, both of which are psychological mechanisms associated with depression. Visible minority status may also enhance alienation and in some cases lead to actual persecution. Cultural differences can result in miscommunication between the minority and majority populations. For individuals predisposed to psychosis, these experiences can lead to enhanced suspiciousness and to psychotic episodes. This conclusion is supported by findings demonstrating that peer victimisation in childhood increases the risk for psychotic symptoms, independent of prior psychopathology or family adversity (Schreier et al., 2009). It is possible that individuals who are prone to psychosis or suffering from paranoid ideation are likely to perceive neutral or ambiguous situations as discriminatory (Berg et al., 2011).

The primary clinical implication of an association between stress sensitivity and psychosis is that stress alleviation techniques may be beneficial for people with psychotic experiences (PE) (ie hallucination-like or delusion-like symptoms that do not meet diagnosable criteria due to insufficient intensity, persistence, or associated impairment) (DeVylder et al., 2016). Interventions that alleviate perceived stress may be efficacious in reducing symptom severity among individuals with psychotic disorders, or may be potentially efficacious in preventing or delaying psychotic disorder onset among help-seeking youth with sub-threshold psychosis (ie, youth at clinical high-risk for psychotic disorder) (DeVylder et al., 2016). For example, mindfulness training has been shown to have moderate efficacy for people with psychotic disorders in a recent meta-analysis (Khoury et al., 2013). Physical exercise, which can reduce stress, has likewise been shown to alleviate psychotic symptoms in a meta-analytic study (Firth et al., 2015). Stress sensitivity can be directly addressed through psychotherapeutic approaches such as cognitive-behavioural therapy, which has shown to be efficacious in treating psychotic symptoms, even in individuals with schizophrenia who are not taking antipsychotic medications (Morrison et al., 2014). Stress alleviation is likewise a key component of attempts to prevent or delay the onset of schizophrenia in help-seeking youth at clinical high risk, among whom cognitive therapy and supportive therapy appear to be beneficial (Thompson et al., 2015). 

Racial-ethnic minority or immigrant status is a consistent risk factor for schizophrenia in European and American studies (Adriaanse et al., 2014; Morgan et al., 2009; Paksarian et al., 2016; Vanheusden et al., 2008). Longitudinal studies have found that psychosis-like symptoms predict subsequent psychotic disorder in both adolescents (Zammit et al., 2013) and adults (Werbeloff et al., 2012).

Substantive research shows that basic schizophrenia symptoms such as hallucinations, anhedonia, antisocial behaviour, depressive symptoms, emotional processing, and mood induction, vary across cultures (Bae & Brekke, 2002; Bauer et al., 2011).

In Asian countries, for example, Japan, the exact meaning of the word schizophrenia translated means, “split-mind disease” (Kim & Berrios, 2001). This terminology is a very “powerful and stigmatizing” label in Japanese, Korean and Chinese cultures with serious implications for patients (Kim & Berrios, 2001). Psychiatrists in Asian societies are less likely to reveal a diagnosis of schizophrenia to family members and to patients (Kim & Berrios, 2001). Kim and Berrios (2001) found that in Japan, only 16.6% of patients knew their own diagnosis, and only 33.9% of their family members did (Kim & Berrios, 2001). In addition, psychiatrists often gave euphemistic diagnoses, such as “neurasthenia” or “autonomic nervous dysfunction” instead of the real diagnosis, making the prognosis and treatment even more complicated. Kim and Berrios (2001) regarded this phenomenon as so serious and ingrained that they suggested a renaming of the disease in ideographic cultures to promote transparency and easier communication.

Peoples from Asian, Middle Eastern and African backgrounds may use traditional healers alongside western models of care. For example, among Southeast Asian groups, Vietnamese families might seek out Taoist teachers and ethnic health practitioners such as Vietnamese physicians, Cambodian and Lao families might use Buddhist monks (Versola-Russo, 2006). The use of traditional medicine has to do with belonging to a collective culture and strong ties to the extended family. When a person is ill, many of the family members are involved in deciding if the client is ill, the extent of the illness, the treatment to be given, and by whom (Versola-Russo, 2006). Rather than viewing traditional healing as a barrier, it should be viewed as a strength and resource. Showing an understanding of the role of traditional medicine helps clinicians to build rapport with the client and family. The use of herbs is common among Asian groups. However, this practice may interfere with the efficacy of psychotropic medications. Fundamental Asian health beliefs that may impact mental health treatment include imbalance of the yin and yang, and the corresponding conditions of “hot” and “cold”. Illness may be attributed to an upset in this balance of forces.

Kim, Bean, and Harper (2004) present eleven specific guidelines when working with Asian clients and families: Assess support systems; assess immigration history; establish professional credibility; provide role induction; facilitate "saving face"; accept somatic complaints; be present/problem focused; be directive; respect family structure; be non-confrontational; and provide positive reframes.

Culture shapes the way in which families respond to schizophrenia. An understanding of a client's cultural heritage can improve the quality of the relationship between the mental health professional and client (Versola-Russo, 2006). Family education and ongoing support is beneficial in order to maximise the support the family network can provide the client. This is especially critical when the client is under the direct care of the family. The extended family is important, and any illness concerns the entire family. Mental health professionals should be mindful that decision-making varies with traditional family structures.

In Asian cultures, families generally do not institutionalise family members. They care for them in the home. Asian families are more likely to accompany the schizophrenic client on clinic visits and to actively participate in treatment decisions (Bae & Brekke, 2002). Collectivist cultures emphasise family integrity, harmonious relationships, and sociability. Bae and Brekke (2002) note the importance of incorporating cultural characteristics into the intervention process. Interventions that are designed to involve families in a collaborative effort may be more appropriate for clients from CALD backgrounds because of the interdependent nature of collective family dynamics.